- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.98 / $61.45 / $72.47
| Professional | | $57.98 | $61.45 | $72.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,148.36 / $14,148.36 / $17,226.00
| Facility | | $14,148.36 | $14,148.36 | $17,226.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,148.36 / $14,148.36 / $26,136.00
| Professional | | $14,148.36 | $14,148.36 | $26,136.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,148.36 / $14,148.36 / $14,148.36
| Facility | | $14,148.36 | $14,148.36 | $14,148.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,148.36 / $14,148.36 / $14,148.36
| Professional | | $14,148.36 | $14,148.36 | $14,148.36 |